1. Profile of the participants
Family planning acceptors or clients were married men and women aged between 18 and 40 years, having at least one child and residing in rural areas of the selected districts. The educational status ranged from being illiterate to college graduates. All women clients were housewives. All family planning acceptors belonged to lower, lower middle or middle income groups. ASHAs were women belonging to the village they served and their educational status ranged from completing high school to graduation.
The other stakeholders which included service providers, development partners and decision makers were minimum graduates and had an experience of at least 2 years in implementation or service provision of family planning programs.
2. Uptake of FP methods
All stakeholders unanimously agreed that among limiting family planning methods, female sterilization was the most popular by far. Women generally preferred this method once their family was complete. It was perceived as a simple “onetime” solution, with relatively lesser associated side effects or chance of complications.
Male sterilization, on the other hand, was least popular of all the methods. There is a widely accepted myth in the community that it makes the man “weak” and therefore may impair his ability to work and earn for the family thereafter.
“Why should my husband get NSV…. he is the bread-winner of the family…. if he becomes weak then what will happen to us” – A woman client who had undergone sterilization
Among spacing methods, condoms, IUCDs and OCPs were the most preferred, although there were many myths or misconceptions linked to IUCDs and OCPs in the community. Uptake of spacing methods has been increasing over the past few years, although many still preferred traditional methods like calendar method or withdrawal method for spacing pregnancies. Injection DMPA and Centchroman pills, which were recently introduced (2017) in the public health system, are yet not as popular due to lack of information about them among general public in the study districts.
3. Factors influencing the decision on uptake of FP method
Factors which emerged as key influencers of client decision to take up an FP method in the two study districts are following:
3.1. Felt need for a small family: Felt need for a small family emerged as the single most important driving factor for uptake of a family planning method in the two study districts. Almost all the clients who had opted for a limiting method stated that they took the decision as they had achieved their desired family size and did not wish to have more children. They cited increased costs associated with managing care and education of children and emphasized that smaller families are easier to manage with the means available. Participants from other stakeholder groups also identified the felt need for smaller families as the primary motivating factor behind couples’ decision to adopt a permanent family planning method.
“Getting sterilization is good forever. It will be good as the number of children will be less. We will be able to feed them well, take good care of them and educate them well.” – Female sterilization acceptor
3.2. Health concerns: Almost all the PPIUCD clients, who accepted the method after their delivery, stated that they wanted to adequately space their subsequent pregnancies. They feared that frequent pregnancies would make them “weak” and “sick” and this would also adversely affect the health of their children. ASHAs or their motivators agreed that health concerns around closely spaced pregnancies was an important factor influencing clients to take up spacing methods like IUCDs, pills or condoms.
Majority of men who opted for NSV stated that they did so out of concern for the health of their wives. They stated that they felt their wives were not healthy enough to undergo a surgery (female sterilization procedure) and therefore took the decision to undergo sterilization themselves.
3.3. Motivation by Sahiya/ASHAs: All health service providers, decision makers and development partners noted that motivation of clients by ASHAs played a very important role in uptake of family planning services. Majority of women clients reported that ASHA of her village was one of the primary sources of information on FP methods and that they always trusted her to give the correct information and guidance. ASHAs too stated that motivating clients to take up a method was their primary role with respect to family planning program and they had to follow up several times with some couples to motivate them to opt a method. They also reported the need to sometimes motivate family members of clients for ensuring that they take up the method of their choice.
3.4 Advise by family members, friends or neighbours: Many clients stated that their decision to opt for a family planning method was taken after consulting their partner, mother in law or any other family member who had used the method before. A few clients also mentioned taking advice of their neighbors and friends before opting for the method.
3.5 Myths and misconceptions on methods: It emerged that there were many myths and misconceptions prevalent in the community regarding spacing methods like the IUCD and OC pills, which served as a deterrent to their uptake. With respect to NSV, there is a widely prevalent myth that it makes the man weak or less masculine, and therefore even women don’t want their husbands to take it up.
3.6 Asymmetric information on methods: It was also evident that counselling or information provided to clients on FP methods was inadequate. Although the ASHAs reported giving information to clients on all available choices, majority of the clients denied being informed about other available options during their decision making process. When probed, majority of the clients were not able to elaborate on the expected side effects of the methods they were currently using. However, the clients felt that their information base was sufficient for them to make an informed choice.
3.7 Other factors: Religious norms and preference for a male child also influenced the uptake of FP services. A couple of clients did state that they opted for female sterilization after having a male child, as after that they felt their family was complete. Few ASHAs and service providers pointed out that uptake of female sterilization was very low in tribal areas and Muslim dominated communities, owing to their cultural and religious norms.
3. b. Influence of financial incentives on client’s decision to opt for a FP method
All clients, including both women and men, categorically stated that their decision to opt for a family planning method was primarily driven by their felt need to limit or space subsequent births. They said that they would have opted for the method irrespective of whether government provided them with financial incentives or not.
“The government gives us (financial incentive) or not it doesn’t matter to us. We have a desire to do NSV, so we go and get it done.” – NSV Client.
Many clients did welcome the financial incentives though and said they felt happy about the amount that the government was providing. Most of them stated that they utilized the money to take good care of themselves by eating nutritious food and buying medicines, to help them recuperate from the surgery. A few clients said that the money helped them compensate for their travel expenses, wage losses or expenses incurred in availing these services at the public health facilities.
A couple of clients informed that they were not aware of any financial incentive attached with the method of their choice until after the procedure.
Majority of Sahiyas and service providers echoed the same sentiment that clients would avail FP services irrespective of financial incentives due to their felt need. However, few of them did state that financial incentives may be a primary driver for clients belonging to the lower socio economic strata of the society.
Decision makers and members of development partner agencies however attached more importance to financial incentives for clients and felt that they were important drivers of family planning uptake, especially for those from lower socio economic strata of the society.
“We belong to a district where there is lot of poverty, and I think this incentive people should get”- District level official
Couple of decision makers also suggested increasing the amount of financial incentives for clients, especially those attached with spacing methods, to improve uptake of FP methods in their area.
4. Influence of financial incentives on service provision by ASHAs or motivators
It was evident that financial incentives play a very key role in motivating ASHAs for performing their family planning program related duties. ASHAs are not salaried employees and therefore the financial incentives attached with their different duties are the primary source of income for them.
Majority of the ASHAs clearly stated that financial incentives attached to their FP related work are very important to them. Many of them were able to recall the exact amount they had received as incentives for family planning in the past one year. Few of them also emphasized that the amount given was not commensurate with the ‘hard work’ they put in and therefore should be increased. Some also expressed displeasure over delays in payment, which they felt was demotivating.
“We do this work and we like doing it. Our incentive money should also be released on-time. We do our work fully but if the amount is paid in time so we will do the work happily. We work everywhere and also want to do a better work, so that we get the cash rewards at a proper time interval” – ASHA, Chatra district.
Participants from other stakeholder groups agreed that financial incentives served as a key motivation factor for Sahiyas to do their work. Some of them agreed with the demands of ASHAs for increasing the amount of financial incentive for them. They also emphasized on ensuring timely payment to them for keeping their motivation levels high.
A couple of service providers and members of development partners did raise concerns on selective promotion of FP methods, which have incentive amounts associated with them, by the ASHAs.
“ASHA is more motivated to give as much information as possible for these methods (attached to incentives).” – Member of Development Partner
5. Influence of financial incentives on service provision by nurses and doctors
It emerged that for doctors, nurses and ANMs, who are salaried employees, the financial incentives served as an extrinsic motivation for carrying out their family planning related work. It was perceived as a ‘token of appreciation’ from the government for their efforts. Majority stated that the amount was important to them, however they did add, that they would continue to provide their services irrespective of whether they received the incentive amount or not.
Participants from other stakeholder groups (government officials, development partners) agreed that financial incentives were important motivators for the nurses and doctors as well. A few of them also felt that different amount of incentive money for different methods does influence service provision by ANMs and nurses as they tend to ‘push’ those methods which have incentives associated with them.
6. Perspectives on discontinuing financial incentives
6.1 Discontinuing client incentives
There were mixed opinions on discontinuing financial incentives for clients. While all clients stated that they would have opted for the method irrespective of whether financial incentives were attached to them or not, some of them did emphasize that the incentive amount was also important for them. Few clients said that although the amount does not matter to them, but it may be important for the poorer clients.
Among the ASHAs, majority felt that discontinuing financial incentives for clients will adversely impact FP uptake to some extent, as there is a section of clients for whom incentive money is an important motivating factor. Remaining ASHAs, on the other hand felt that owing to the strong felt need for FP methods, discontinuing financial incentives for clients would not have any adverse effect.
Majority participants from the other stakeholder groups concurred that discontinuing incentives will adversely impact uptake of family planning services especially among the poorer sections or among those living in remote locations. Government officials particularly were not in favor of discontinuing client incentives in one go. A government official stated that one needs to first study the impact by discontinuing incentives in a few districts and then come to a conclusion.
“A pilot project needs to be conducted to see what the effect in the region is once it is withdrawn and then compare it with other region. If all are withdrawn all of a sudden then there will be problem” – A government official, Jharkhand
6.2. Discontinuing incentives for ASHAs and service providers
Almost all Sahiyas clearly stated that financial incentives were their primary motivation to work. Many stated that unlike other service providers, they were not salaried employees and entirely depended on these financial incentives to run their families. Few also put forward their demand to increase the amount of incentives for them as it was not commensurate with the amount of effort they were putting in
“We are working for the money only, either it is less or more. If we don’t get money how will we work? “– ASHA
Nurses, doctors, government officials and development partners, all echoed the same sentiment and opined that FP services would be impacted majorly if incentives for ASHAs were scrapped. ASHAs played a key role in motivating clients and any step which de-motivates them would have major implication on the FP program.
ANMS, Nurses and doctors stated that discontinuing incentives for them would not affect the services that they provide as they were being paid (salary) to give their services.
Government officials and development partners though expressed their concern that scrapping incentives for service providers may adversely affect their motivation levels especially of nurses and junior doctors and therefore may have an adverse effect on the program. They emphasized that service providers receive financial incentives for their work across many health programs like maternal health, immunization etc. and scrapping incentives in the family planning program may demotivate them from actively giving services for the program.
“The doctor and the assistant get motivated when they get incentive because there is a series of incentives in all programs. Like in maternal health (MH) caesarean section, the doctor, nurse and even the 4th grade gets incentive. So if you give in some program and not in some, it will demotivate people” - A district level government health official.
7. Perspectives on replacing financial incentives with non-monetary incentives
7.1. For clients
Many clients stated that they would be fine with any non-monetary incentive which the government offers them in place of cash like food items, clothes etc. Some did convey that they would prefer cash incentives as it would give them the freedom to buy things as per their needs. ASHAs too had a mixed opinion on the issue. Many of them felt that clients will appreciate non-monetary incentives more as they would get it right after accepting a method and would not have to wait like in case of financial incentives. A few of them stated that clients use the incentive amount for purchasing nutritious food items to help them recuperate better after surgery and therefore replacing financial incentives with nutritious food items would be a better option as payment of financial incentives does get delayed sometimes. A few ASHAs did however feel that financial incentives were better off as they gave clients the freedom of using it in their own desired way.
Service providers, government officials and development partners were more inclined towards continuing with financial incentives as non-monetary incentives may not meet every client’s requirement. They also raised the issue of increased chance of corruption with disbursement of non-monetary items. Some government officials also pointed out the logistical challenges in distribution of non-financial incentives, which they felt would be a major barrier.
7.2. For ASHAs and service providers
For ASHAs, there was agreement among most respondents on the need for financial incentives, as they were not salaried and these financial incentives were their only source of income.
For ANMs, nurses and doctors, there were mixed opinions. While many service providers themselves stated that the ‘token of appreciation’, either monetary or non-monetary, would motivate them, government officials and development partners were more inclined on continuing with the financial incentives. They felt that non-financial incentives like certificates or rewards for good performance could be supplemented with monetary incentives. However, they were not in favor of completely scarping monetary incentives as they felt it was important for their continued motivation.
“It will impact, but not their pro-activeness as monetary would. Though “recognition” matters but it doesn’t give a push like money” – Member of a development partner on whether non-monetary incentives would motivate service providers.
8. Issues with disbursement of financial incentives
Delay in payment of incentives was reported by some clients and ASHAs. Many participants emphasized on the need to ensure early payment of incentives, especially for the ASHAs and the clients, for keeping their motivation levels high.
ASHAs highlighted the importance of timely payment to the clients stating that delays adversely affect their relationship with their clients who then tend to lose their trust in them. This, they said hampers their work as people in her area start doubting her intentions and words.
“So then sometimes beneficiary starts talking and doubting us, asking what is the reason that Sahiya (ASHA) is not making us get our incentives.” – ASHA
Government officials acknowledged that delays do happen in certain cases when the clients do not have a bank account or the documentation isn’t complete from their end. They however did point out that such instances are now reducing as more and more clients are getting their bank accounts opened. They stated that the primary reason for this delay is at the client level (documentation issues), temporary unavailability of funds and lack of human resources.